INITIATE CLAIM APPLICATION - Mississippi · 2020-05-06 · UI-501 UNEMPLOYMENT APPLICATION PAGE 1...

UI-501 UNEMPLOYMENT APPLICATION PAGE 1 OF 26 MDES: REV-05062020

INITIATE CLAIM APPLICATION

*REQUIRED INFORMATION

1. *Are you unemployed as a result of a major disaster which occurred in Mississippi and was

declared by the President? COVID-19: YES NO

2. If disaster is MS COVID-19: effective beginning January 27, 2020 check all that apply:

I have been diagnosed with COVID-19 or am experiencing symptoms of COVI0-19 and am seeking a medical diagnosis;

A member of my household has been diagnosed with COVID-19;

I am providing care for a family member or a member of my household who has been diagnosed with COVID-19;

A child or other person in my household for which I have primary caregiving responsibility is unable to attend school or another facility that is closed as a direct result of the COVID-19 public health emergency and such school or facility care is required for me to work;

I am unable to reach the place of my employment because of a quarantine imposed as a direct result of the COVID-19 public health emergency;

I am unable to reach the place of my employment because I have been advised by a health care provider to self-quarantine due to concerns related to COVID-19;

I was scheduled to commence employment and do not have a job or am unable to reach the job as a direct result of the COVID-19 public health emergency;

I have become the breadwinner or major support for a household because the head of the household has died as a direct result of COVID-19;

I had to quit my job as a direct result of COVID-19; or

My place of employment is dosed as a direct result of the COVID-19 public health emergency.

I am self-employed and unable to work due to COVID-19.

3. *Date you became unemployed as a direct result of the disaster:

_________ - __________ - _____________________


FILE DISASTER CLAIM


1. *County where you were employed before the disaster:

_______________________________________________________

2. *County where you lived at the time or disaster

_______________________________________________________


UI-501 Unemployment Application

Date: __________ - __________ - ______________________ NOTE: PLEASE SHOW ALL DATES AS MM-DD-YYYY (MONTH, DAY, YEAR)

PERSONAL INFORMATION

1. SSN : __________ - ______ - _____________ 2. First Name: _________________________________

3. Middle Initial: _______ 4. Last Name: _________________________________________

5. Other last name worked under during the last 18 months: ___________________________________

6. Date of Birth: __________ - __________ - ______________________

7. Gender: MALE FEMALE

8. Race: ASIAN AFRICAN AMERICAN CAUCASIAN AMERICAN INDIAN PACIFIC ISLANDER

9. Ethnicity: NOT HISPANIC/LATINO HISPANIC/LATINO

10. Are you a US Citizen? YES NO If No, provide the following

a. Alien Document Type: VISA PERMANENT RESIDENT 1-55

b. Document #: _________________

c. Exp. Date: __________ - __________ - ______________________

11. Do you have a disability? YES NO

12. Are you a military veteran, transitional veteran or a spouse of a veteran? YES NO

13. What is the highest grade completed in school? _________________

14. Do you have a state issued driver’s license or identification card? YES NO

a. If yes, indicate the issuing state ______________________________


IDENTIFICATION VERIFICATION

1. First name (on ID or DL) : _______________________________________

2. Last name (on ID or DL): _______________________________________

3. Date of Birth (on ID or DL): __________ - __________ - ______________________

4. Driver’s License/ID Number: _______________________________________

5. License Class: _______________________________________

6. Issue Date:__________ - __________ - ______________________

7. Expiration Date:__________ - __________ - ______________________

8. Height: _______Feet _______Inches

If the details entered cannot be validated, your claim will be subject to further identification

verification.

CONTACT DETAILS

1. Mailing address: Street: _______________________________________________________

City: ____________________________ State: _____________________________________

Zip Code: ____________________ Country: _______________________________________

Residential address: Same as mailing address Different

2. Residential address: Same Different

3. If different, provide details: Street: _______________________________________________________

City: ____________________________ State: _____________________________________

Zip Code: ____________________ Country: _______________________________________

4. If Mississippi resident, County: _______________________________

5. Telephone Number(s)

Primary Number:____________________ 5. Cell Number:____________________

6. Would you like to sign-up to receive notification via text message regarding your reemployment

assistance? Message and data rates may apply. Yes No

7. How may we contact you? USPS Mail Email


EMAIL ACKNOWLEDGEMENT

BY CHECKING “I AGREE”, YOU AGREE AND CONSENT TO RECEIVE NOTIFICATION OF UNEMPLOYMENT

INSURANCE CORRESPONDENCE BY EMAIL. YOU WILL RECEIVE AN EMAIL STATING “I AGREE TO THE TERMS

AND CONDITIONS OF MDES REGARDING ELECTRONIC NOTIFICATIONS.” BY PROVIDING YOUR EMAIL ADDRESS,

YOU CAN RECEIVE IMPORTANT INFORMATION FASTER AND MORE EFFICIENTLY. YOU CAN ALSO RESET YOUR

PASSWORD USING OUR CONVENIENT AUTOMATED SYSTEM.

I agree

8. Email Address: _______________________________________

9. Confirm Email Address: _______________________________________

10. Select your correspondence language preference: ENGLISH SPANISH

SECURITY CONFIRMATION

MDES WILL VALIDATE THE IDENTITY INFORMATION YOU PROVIDED WITH OTHER STATE AND FEDERAL AGENCIES.

REVIEW THE INFORMATION AND MAKE ANY NECESSARY CHANGES.

1. Social Security Number: __________ - ______ - _____________

2. First Name on SS card: _______________________________________

3. Last Name on SS card: _______________________________________

4. Date of Birth: __________ - __________ - ______________________


FILE CLAIM

1. Mark the location where you are filing the claim.

CALL CENTER WIN JOB CENTER OTHER

2. Were you employed with the federal government performing federal civilian service

within the last 18 months? YES NO

If yes, where did you work? IN USA OUTSIDE USA IN MISSISSIPPI

3. Were you discharged from the US Military within the last 18 months? YES NO

4. Have you worked for any employer within the last 18 months? YES NO

5. List all the states where you worked within the last 18 months,

excluding Federal (Outside of USA) or Military employment.

MISSISSIPPI

STATE #1: _______________________________________ STATE #2: _______________________________________

6. Do you have a definite date to return to full time work? YES NO

a. If yes, indicate the date you expect to return to work below:

__________ - __________ - ______________________

7. Have you applied for Unemployment Insurance Benefits in any state

other than Mississippi in the last 12 months? YES NO

8. Was your last employer a Headstart employer? YES NO

9. Are you currently unemployed due to the novel coronavirus outbreak (also known as COVID-19)?

YES NO


EMPLOYMENT DETAILS (EMPLOYER #1)

Employer Name: ________________________________________________

Street: _______________________________________________________

City: ____________________________ State: ____________________________

Zip Code: ____________________ Country: ____________________________

1. Did you work for this employer? YES NO

a. Start Date: _____ - _____ - _____________ b. End Date: _____ - _____ - _____________

c. Job Title/Description: ______________________________________

d. What was your rate of pay? Amount: _____________________

RATE OF PAY: HOURLY DAILY WEEKLY BI MONTHLY MONTHLY YEARLY

e. Reason why you are no longer working with this employer:

LACK OF WORK/LAID OFF DISCHARGE VOLUNTARY QUIT CORONA VIRUS (COVID-19)

LEAVE OF ABSENCE DESIGNATED VACATION STRIKE/LOCKOUT SUSPENSION

i. If Voluntary Quit, select reason:

ATTEND SCHOOL/TRAINING CHILD CARE DISTANCE TO WORK

FAMILY RESPONSIBILITIES HEALTH REASONS MOVE WITH SPOUSE

MOVE WITH SPOUSE-MILITARY NOT PAID CORRECT AMOUNT REDUCED WORK HOURS

RELOCATE START A NEW JOB TO GET MARRIED TRANSPORTATION OTHER

ii. If Discharged/Fired, select reason:

ABSENTEEISM/TARDINESS AWAY FROM WORK STATION DAMAGING COMPANY PROPERTY

FAILED DRUG TEST FALSIFIED DOCUMENTS POOR JOB PERFORMANCE

PHYSICAL ALTERCATION REFUSING TO PERFORM ASSIGNED DUTIES

REFUSING TO WORK OVERTIME SLEEPING ON THE JOB STEALING

SUSPENDED DRIVER’S LICENSE UNAUTHORIZED USE OF COMPANY PROPERTY

UNDER THE INFLUENCE OF ALCOHOL VERBAL ALTERCATION OTHER

f. Are you receiving or are you going to apply for a pension from this employer? YES NO

I. IF YES, PROVIDE THE DATE YOU RECEIVED OR WILL RECEIVE THE PENSION BELOW:

__________ - __________ - ______________________

g. Employer Telephone #: ___________________________________________

h. Are you being paid by this employer during the time you are off work? Yes No



Employer Name: ________________________________________________

Street: _______________________________________________________

City: ____________________________ State: ____________________________

Zip Code: ____________________ Country: ____________________________























__________ - __________ - ______________________




ADD EMPLOYMENT DETAILS


1. *Employer Name: _______________________________________________________

2. *Employer Address Line 1: _______________________________________________________

*Address Line 2: _______________________________________________________

*City: ____________________________ *State: ____________________________

*Zip Code: ____________________ *Country: ____________________________

3. *Start Date: _____ - _____ - _____________ 4. *End Date: _____ - _____ - _____________

5. *Work Location: a. City: ____________________________ b. State: ___________________________

6.. *Job Title/Description _______________________________________________________

7 *What was your rate of pay? Amount: _____________________

*RATE OF PAY: HOURLY DAILY WEEKLY BI MONTHLY MONTHLY YEARLY

8. *Reason why you are no longer working with this employer: LACK OF WORK/LAID OFF DISCHARGE VOLUNTARY QUIT CORONA VIRUS (COVID-19)


a. If Voluntary Quit, select reason:





b. If Discharged/Fired, select reason:







9. *Total wages earned since October 1, 2018: ________________________

10. *Are you receiving or are you going to apply for a pension from this employer? (Do not lnclude severance pay or soclal security benefits.) YES NO

a. IF YES, PROVIDE THE DATE YOU RECEIVED OR WILL RECEIVE THE PENSION BELOW:

__________ - __________ - ______________________

11. *Employer Telephone #: ___________________________________________

12. *Are you being paid by this employer during the time you are off work? Yes No


APPLICATION FOR RECONSIDERATION OF WAGES


1. *Employer Name: _______________________________________________________

2. *Employer Address Line 1: _______________________________________________________

*Address Line 2: _______________________________________________________

*City: ____________________________ *State: ____________________________

*Zip Code: ____________________ *Country: ____________________________

3. *Start Date: _____ - _____ - _____________ 4. *End Date: _____ - _____ - _____________

5. *Owner of the Business: _______________________________________________________

6. *Name/Title of the person who hired you: ________________________________________________

7. *Employer Telephone #: ___________________________________________

8. *FEIN: ________________________________________________

9. *Doing Business As (MUST NOT EXCEED 100 CHARACTERS)

10. *Nature of employer’s business (MUST NOT EXCEED 250 CHARACTERS)

11. *Directions to the employer’s business (MUST NOT EXCEED 250 CHARACTERS)


12. *Approximately how many people worked for this employer? _____________________

13. *Type of work you performed? ________________________________________________________

14. Work Location: City: ____________________________ State: ____________________________

15. *Were you paid directly by the employer above? YES NO

a. If No, who paid you? _____________________________________

16. *How were you paid? CASH CHECK OTHER

17. *Select the document( s) that you received from this employer W-2 1099 OTHER

18. *Did you work under another Social Security Number? YES NO

a. If Yes, provide the other SSN : __________ - ______ - _____________

19. *Enter the quarterly gross wages you earned (including tips, bonuses and commission).

QUARTER/YEAR EMPLOYER REPORTED WAGES ($) CLAIMANT REPORTED WAGES ($)

Oct-Dec 2018

Jan-Mar 2019

Apr-Jun 2019

Jul-Sep 2019


SELF-EMPLOYMENT QUESTIONNAIRE


To be ellglble for Unemployment Insurance benefits, you must be able and available to seek and accept full time work.

1. *Describe your self-employment activities (Must not exceed 1000 characters)

2. *How many hours per week do you spend seeking or performing self-employment?

3. *Are you seeking full-time work other than your self-employment? Yes No

a. If Yes, what other types of work are you seeking? (Must not exceed 1000 characters)



Employer Name: ________________________________________________

Street: _______________________________________________________

City: ____________________________ State: ____________________________

Zip Code: ____________________ Country: ____________________________























__________ - __________ - ______________________





Employer Name: ________________________________________________

Street: _______________________________________________________

City: ____________________________ State: ____________________________

Zip Code: ____________________ Country: ____________________________























__________ - __________ - ______________________




ABLE AND AVAILABLE DETAILS

1. Are you currently self-employed? YES NO

2. Have you refused an offer of work since your last day of employment? YES NO

3. Are you presently attending school or training? YES NO

4. Can you accept full-time work immediately? YES NO

If no, why?

5. Are you pregnant? YES NO

If yes, enter your expected delivery date: __________ - __________ - ______________________

TAX WITHOLDING AND PAYMENT OPTION

1. Do you want to have 10% of your Unemployment Insurance Benefits payments, including

Federal Additional Compensation, withheld for Federal Income Tax? YES NO


LACK OF WORK QUESTIONNAIRE (EMPLOYER #1)

1. When were you told of the lack of work (date)? __________ - __________ - ___________________ .

2. Who told you of the lack of work (name and title)? _______________________________________

3. Were you given written notice of the lack of work? YES NO

4. Were you the only person laid off? YES NO

5. Were you provided severance pay? YES NO

6. Select the reason you were told for the lack of work:

REDUCTION IN FORCE CONTINUING WORK NOT AVAILABLE POSITION ELIMINATED

TEMPORARY LAYOFF PINK SLIP CORONA VIRUS (COVID-19) OTHER

a. If other, provide as much detail as possible: Click below to enter text.


LACK OF WORK QUESTIONNAIRE(EMPLOYER #2)

































ADD MILITARY EMPLOYER

1. Service Branch

ARMY NAVY AIR FORCE MARINES COAST GUARD

2. Service Start Date: __________ - __________ - ___________________ .

3. Service End Date: __________ - __________ - ___________________ .

4. Have you applied for (or) are you receiving a pension from the military?

YES NO

5. Do you have your DD-214 Member 4 copy?

YES NO

Only complete the next page if you have worked

for federal service in the last 18 months


FEDERAL EMPLOYER

1. Federal Agency Name: _____________________________________________________________

2. Mailing Address: Street: _______________________________________________________

City: ____________________________ State: ____________________________

Zip Code: ____________________ Country: ____________________________

3. Did you receive form SF-8 from this Federal Agency? YES NO

4. Location of your last Federal employment prior to your separation

City: ____________________ State: ______ Country: ____________________________

5. If you performed Federal Civilian Service outside of the United States, were you

the spouse of a military service member stationed at a military base? YES NO

6. Employment Start Date: _________ - __________ - _____________________

7. Employment End Date: _________ - __________ - _____________________

8. Did you perform Federal civilian service while employed with this Federal agency? YES NO

9. Reason you are no longer working with this employer:

LACK OF WORK/LAID OFF DISCHARGE VOLUNTARY QUIT


I. IF VOLUNTARY QUIT, SELECT REASON:






ABSENTEESIM/TARDINESS AWAY FROM WORK STATION DAMAGING COMPANY PROPERTY







10. Have you applied for a pension or, are you receiving a pension from this employer?

YES NO

11. Did you receive or are you entitled to receive severance pay provided by any federal law or

agency-employer agreement? YES NO

If yes, complete the following

A. WEEKLY AMOUNT ____________________

B. NUMBER OF WEEKS ____________________

C. TOTAL ENTITLEMENT $ ____________________

D. SEVERANCE PAY START DATE: _________ - __________ - _____________________

E. SEVERANCE PAY END DATE: _________ - __________ - _____________________

F. DATE OF PAYMENT: _________ - __________ - _____________________

12. Enter the quarterly gross wages, including tips, bonuses and commission.

These wages will be used to determine your monetary eligibility

Affidavit of Wages

QUARTER/YEAR WAGES

YOU MUST PROVIDE PROOF OF WAGES WITHIN FIVE CALENDAR DAYS OF COMPLETING THIS

APPLICATION. YOU SHOULD UNDERSTAND THAT PENALTIES ARE PROVIDED BY LAW FOR AN INDIVIDUAL

THAT MAKES FALSE STATEMENTS TO OBTAIN BENEFITS. ANY DETERMINATION BASED ON THIS AFFIDAVIT

IS NOT FINAL; DETERMINATIONS ARE SUBJECT TO CORRECTIONS UPON RECEIPT OF WAGES AND

SEPARATION INFORMATION FROM THE FEDERAL AGENCY WHERE YOU WORKED. BENEFIT PAYMENTS

MADE AS A RESULT OF SUCH DETERMINATION MAY HAVE TO BE ADJUSTED ON THE BASIS ON THE

INFORMATION FURNISHED BY THE FEDERAL AGENCY, AND ANY AMOUNT OVERPAID MUST BE REPAID OR

OFFSET AGAINST FUTURE BENEFITS.

YOU MAY RETURN THIS COMPLETED FORM BY EMAIL TO [email protected]


HOW TO SET UP YOUR ACCOUNT FOR DIRECT DEPOSIT

Go to WWW.MDES.MS.GOV to set up direct deposit for payment of your Unemployment Benefits:

Select ONLINE UNEMPLOYMENT SERVICES under the UNEMPLOYMENT CLAIMS tab, and log in to your account;

Select BENEFITS MAINTENANCE tab;

Select UPDATE CLAIMANT PROFILE tab and then select PAYMENT OPTIONS tab.

Enter the following under PAYMENT OPTIONS:

NAME ON BANK ACCOUNT (referring to the owner of the account)

ACCOUNT TYPE (savings or checking)

BANK ACCOUNT NUMBER

CONFIRM BANK ACCOUNT NUMBER

BANK ROUTING NUMBER

CONFIRM BANK ROUTING NUMBER

PLEASE REVIEW THE INFORMATION ENTERED TO BE SURE IT IS CORRECT TO AVOID DELAY.

DEBIT CARD PROCEDURES

If you have been issued a debit card and it has not expired, this will be the same card for receiving your UI benefits.

If you have been issued a debit card within the past three years and it has been lost, stolen, or damaged, contact the following number to request a replacement: 1-866-461-4095. Fees do apply: $5.00 for normal delivery and the current $21.00 fee for expedited delivery.

The debit card for UI looks exactly like the debit card for child support. The only difference is the card for UI has a U printed on the front of the card on the bottom left. This is how to distinguish the two cards. Funds for UI will not go onto the child support card.

For a complete list of fees for the debit card, visit https://www.eppicard.com/ and select MS from the drop down menu. Once you select MS, you will be able to access documents, including the complete list of fees and disclosure statement.

Check the balance of your card, free of charge, by creating a user ID and password at https://www.eppicard.com.


HOW TO CREATE AN ACCOUNT for Online Unemployment Services with Mississippi Department of Employment Security

Go to WWW.MDES.MS.GOV

Select ONLINE UNEMPLOYMENT SERVICES

under the UNEMPLOYMENT CLAIMS tab.

On the next screen, click on

CREATE CLAIMANT USER ID.

Provide the information requested on the

NEW USER SIGN UP page.

CREATE your USER ID AND PASSWORD

Passwords must be 8 to 15 characters,

contain at least one uppercase letter, one

lowercase letter, one number and one

symbol (a special character such a !@##”).


INITIAL APPLICATION FOR PANDEMIC UNEMPLOYMENT ASSISTANCE


1. *Marital status: MARRIED SINGLE

2. *Number of dependents ____________________

3. *County where you were employed before ________________________________________

4. *County where you lived at the time of disaster? ________________________________________

5. *Last Occupation _____________________________________________________________

6. *Date you became unemployed as a direct result of the disaster:

_________ - __________ - _____________________

7. Name and Address of Employer (MUST NOT EXCEED 250 CHARACTERS)

Name: _____________________________________________________________

Mailing Address: Street: _______________________________________________________

City: ____________________________ State: ____________________________

Zip Code: ____________________ Country: ____________________________

Note that your employer will be notified that a claim has been filed and will be given the opportunity to provide employment and separation information.

8. Do you have a definite date to return to work? Yes No

a. If yes, enter the date: _________ - __________ - _____________________


INITIAL APPLICATION FOR PANDEMIC UNEMPLOYMENT ASSISTANCE (continued)


9. Select the weeks that you were totally or partially unemployed due to the disaster and for which you are claiming Disaster Unemployment Assistance. Report gross earnings from employment and net earnings for self employment. The week begins on Sunday and ends on Saturday,

SELECT WEEK ENDING DATE HOURS WORKED EARNINGS ($)

10. Were you able and available for work during each of the weeks selected above? Yes No

11. Did you apply for or receive or would you be eligible to receive if you had applied for:

a. *Unemployment Compensation from another State? Yes No

State: _______________________ Amount _______________________

b. *Private insurance for illness or disability pay? Yes No

Type: _______________________ Amount _______________________

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